Provider Demographics
NPI:1417469453
Name:SJMHS LIVINGSTON ORTHOPEDIC SURGICAL GROUP
Entity Type:Organization
Organization Name:SJMHS LIVINGSTON ORTHOPEDIC SURGICAL GROUP
Other - Org Name:ORTHO TRAUMA ST JOES-AA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:RHM CFO SEMI
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:GUSHO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:734-398-0642
Mailing Address - Street 1:7575 GRAND RIVER RD STE 114
Mailing Address - Street 2:
Mailing Address - City:BRIGHTON
Mailing Address - State:MI
Mailing Address - Zip Code:48114-9390
Mailing Address - Country:US
Mailing Address - Phone:810-844-7785
Mailing Address - Fax:810-844-7567
Practice Address - Street 1:5315 ELLIOT DR
Practice Address - Street 2:SUITE 304
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48197
Practice Address - Country:US
Practice Address - Phone:734-712-0655
Practice Address - Fax:734-712-0611
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SJMHS LIVINGSTON ORTHOPEDIC SURGICAL GR
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-10-31
Last Update Date:2017-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XX0801XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic TraumaGroup - Single Specialty